Designation of Another Person to Consent for Dental Care

Designation of Another Person to Consent for Dental Care
It is best that a parent or legal guardian accompanies children for each visit to our dental clinic. However, we understand there may be time when someone other than you take care of your child. If you child must be seen at these times, we require a signed consent to provide dental care.

This consent form allows the person you choose to seek dental treatment and sign consent for your child when you are unable to come with the child.
- The person you name must be 18 years of age or older.
- Please use a separate form for each child.
I, (parent, legal guardian)
Cannot accompany my child (child's name),
Patient date of birth
To Mecklenburg County Public Health Department Dental Clinic. Therefore, I give permission to (person's name)
To (Check one):
Parent/Guardian Signature:
ID of parent or legal guardian
Phone Number:
Format: (000) 000-0000.
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: